HOW DO I ENROLL?

Order Form Information

Page 1 - Demographics:

1.   SL NUMBER: If you are a returning customer and wish to use your "old" SL number, please fill it in.

If you are a new customer, leave this blank; a number will be assigned to you.

2.   SHIP TO: Address where PT samples should be sent. You must list a street address since carriers will not deliver packages to a PO Box. Please include phone/fax numbers and a business email address.

3.   REPORTS TO: Address where mail should be sent. If your facility does not have a mail receptacle at your street address, please provide a PO Box number. Also include phone/fax numbers and a business e-mail address.

4.   BILL TO: Address where invoices/bills should be sent (usually Accounts Payable departments, office manager, etc.). Please include phone/fax numbers and a business e-mail address.

5.   METHOD OF PAYMENT: List the PO number to bill against, if known. We also accept Visa/MasterCard. However for security and audit reasons, please wait for your invoice to arrive and then call the phone number listed on the invoice with your credit card information. You will be invoiced within 30 days of receipt of order. It is NOT necessary to include payment with your order.

We encourage you to fax your order as soon as possible to 608-265-1111. If you are unable to fax, please mail to: WSLH PT, 465 Henry Mall, Rm 402, Madison WI 53706.

6.   MANAGEMENT SERVICES: if your laboratory has a technical consultant, lab director or POCT coordinator who needs a copy of the reports which will be sent to the person listed under "Reports to" section, please provide their information here. Consultants/POCT coordinators responsible for multiple sites can select free group re-enrollment and/or confirmation services to help them manage the PT enrollment process (see page 20 of the 2009 catalog for detailed descriptions).

7.   LAB TYPE: Please indicate the facility type for this site.

Page 2 - Email Options:

1.   COMMUNICATION OPTIONS: Select the option(s) desired. If e-mail communication is not desired, this page can be omitted. Learn more about our electronic communication options, including requesting on-line account access.

Page 3 - Accreditation Information:

1.   CLIA I.D. NUMBER: This is your identification number under the Clinical Laboratory Improvement Amendments of 1988 (U.S. labs only).

2.   ACCREDITATION INFORMATION: Indicate the agency that performs on-site inspections of this site and include any ID number (other than the CLIA ID) which is associated with this accreditation. This insures that PT enrollment records and scores will be sent to the correct accreditation agency.

3.   DESIGNATION OF PRIMARY PT PROVIDER: Customers are required to select the appropriate option. If unsure which option is valid, please call 800-462-5261, ext. 45 for guidance. 

 Page 4 - WSLH Product Codes:

Special Note for customers accredited by the College of American Pathologists’ Laboratory Accreditation Program --  Please refer to information on pages 8-14 of the 2009 catalog to ensure enrollment in our PT program will meet accreditation requirements for your activity (test) menu. 

1.   ORDERING: Indicate the PT products needed by putting the number of sets in the adjoining box. One “set” includes all shipments for the calendar year (normally 2 or 3). Facilities with more than one instrument/kit doing the same testing may need to order multiple sets or use “X”, “Y” or “Z” options (if available) to cover their needs.

• Product Codes ending in “-X” provide an additional set of samples for testing. This option is useful for in-house documentation of training/competency, provides a convenient back-up for breakage/spillage or can be used to troubleshoot problems after PT reports are received. “X” products do not allow reporting of additional results.



• Product Codes ending in “-Y” provide the ability to report another set of results. No additional samples are included. Additional result sets reported must operate under the same CLIA ID#.



• Product Codes ending in “-Z” will provide both an additional sample set and the ability to report additional results.


  Please Note: “X” and “Y” products must be ordered in conjunction with one base (-R) product.

2.   SUB-TOTAL: The amount of all PT products ordered. Note: Prices are divisible by the number of yearly shipments. Customers enrolling after the first of the year will be charged only for the number of shipments they will receive from order process date through the end of the calendar year.

3.   PTPlus PRODUCTS: Binders and the Quality Management Report should be listed in this section. Online competency/training and VeriSamp validation sets have separate order forms. Transfer any amounts from these forms if all services should be billed with the proficiency testing order. Note: Pro-rated pricing (see #2 above) does not apply to PTPlus products.

4.   TOTAL: Add the sub-total, annual enrollment fee and any optional services (e.g. binders, PTPlus products) ordered.